Wednesday, November 2, 2011

More on NHS and C-Sections

Over at BMJ Journal of Medical Ethics Blog, Iain Brassington wonders why, in my earlier post on the new NHS policy permitting c-section on maternal request, I said I was worried about the policy opening the door to c-sections being scheduled for reasons other than maternal request. "It's a heck of a leap from 'maternally requested' to 'requested by someone else," he says.

Well, maybe not such a leap. Allow me to quote myself (and co-author Errol Norwitz) (notes omitted):

"There is extensive support for the idea that some cesareans are performed at the instigation of physicians for reasons unrelated to medical indication. A by-now venerable body of published data demonstrates that the overall cesarean rate is responsive to method of reimbursement, to physician time demands, and to physicians’ fear of medical malpractice lawsuits. This medical literature is supported by the results of a 2006 survey of recent mothers. The survey showed that mothers with primary cesareans indicated that not they, but their physicians, were the predominant decision-makers in choosing the cesarean procedure. A total of 26% of women with primary cesareans reported having felt pressured by their providers to get the procedure. In contrast, only 1 of 252 survey respondents with primary cesareans reported making the choice to schedule a cesarean in advance for no medical reason. Two others who reported having had cesareans for no medical reason reported that the decision to have the cesarean was made by their provider and not by themselves. These data are similar to findings in Brazil, which has a cesarean rate of 36%. Repeated studies there have shown that a majority of primiparous women in Brazil want to delivery vaginally, but end up delivering surgically, particularly in private hospital settings.Their decisions to undergo surgery emerge only after discussions with their physicians; yet the public rhetoric around cesarean section in Brazil is that women are “demanding” the procedure. Finally, consider the striking results of a 2004 paper on intrapartum elective cesarean delivery. Researchers surveyed obstetricians after all intrapartum cesarean deliveries in their facility, asking whether cesarean delivery was offered by the obstetrician or requested by the patient before being medically indicated. Of a sample of 422 cases, cesarean was offered in 13% of cases before any clear medical indication emerged, and requested in only 8.8%. Thus, among intrapartum cesareans without medical indication, more were offered by physicians than were “requested” or “demanded” by patients. Physician characteristics, and not patient characteristics, were a significant factor in determining whether elective cesareans were offered."

In sum: in the US and in Brazil, a lot of what gets talked about as c-section on maternal request is physician-driven. Will the new NHS policy open the door to this phenomenon?

Finally, I don't think I said anything inaccurate about the new NHS policy, as Iain gently suggests. I gave a summary account of the steps to be taken under the policy by the physician before the woman's request for c-section is agreed to, and Iain helpfully spells those out. But in the end, if the requesting persists, the c-section is given, even if that requires transfer to another physician's care. My concern is that the initiation of requests, and their persistence, is subject to influence by physicians. At least in the States (where, admittedly, the financial incentives are different), the occasional doc has been known to prefer higher reimbursement to lower, Friday afternoon c-sections to vaginal births on Saturday at 2am, and so on.


  1. Hmmmm - I'd still dispute whether there's all that much of a connection between the NICE guidelines and your worries, for the reasons I suggested in my post: I think that there is - as a matter of bare logic - a leap between provision at the mother's request and provision at the medic's. But, leaving that aside, it seems to remain the case that, if the medic was pressing for a c-section, then NICE guidelines on maternal request would make not a whit of difference. If your obstetrician is the kind of person who is going to pressure you into having a c-section, he's going to be the kind of person to pressure you into having a c-section irrespective of what NICE says about voluntary ones.

    You seem to identify three push-factors that would make a medic more likely to pressurise a woman towards a c-section: method of reimbursement, physician time demands, and fear of medical malpractice lawsuits. The first can, I think, be dismissed fairly easily, since the NHS means that money can be taken out of healthcare provision. Nor am I sure what the grounds would be for any kind of malpractice suit - so I'm tempted to relegate the importance of that.

    That leaves the question of physician time demands. But here, I'm not sure that that makes all that much of a difference, not least because - as far as I understand - most of the medical attention during labour comes from nursing and midwifery staff, rather than doctors (on which, see So it seems that there's actually a disincentive for doctors to encourage unnecessary surgical procedures, because it'll mean that there's more for them to do.

  2. I'm not quite sure I understand how we can say that there is a disincentive for doctors to perform c-sections, though, when the statistics indicate that physicians are more likely to introduce the topic of c-sections than women are. Doesn't this quantitatively determine that doctors are at least neutral on the subject, because a disincentive would at least cause them to wait until the option is brought up by the patient?